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Apr , 29 , 2002 4: 17PM CONDOR EARTH TECHNOLOGIES No . 9363 P . 3/6 <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> GA <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> INION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby mad®to San Joaquin County for a permit to constrvat and/or Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 a)d the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> rwp l" UW#r k o R- A'f-of- IAJa Assessor's <br /> ala 1� ) <br /> WELL Locatlon r 1 r.. Cross Street City 5'i;oellr;I'OYt ZipParceliF 3RD o� �/L4. <br /> 54w,r flllil-'j, 14�KLY blv1 d. _. <br /> PROPERTY Owner 50.4. C�1.-i1a.t-K� Address City ZipPhone# <br /> C-57 Conttactor V IYON4 xNf-• Addrass Z lI0 AJy-m-a A VeYCity l.a­�Yo Zip 14S* tJc# 0 -4_Phone#�14' <br /> CeM aw- +►r'rk /59 Fr-%^k- wtst -JJ <br /> Consultant 1Sub Contractor �Ctr Syt-. X CityfkOcI-+0r%Lic# Phone#.2.Orl <br /> GIS Coordinates:X_ Y� _,Township Range Section <br /> WOR} OBE PERF MED: <br /> EW WELL/BORING(CPT,GEOPROBFy,HYDROPUNCH,HAND-AUGER,OTHER") []DESTRUCTION(choose type below) <br /> �i SOIL BORING# []OVER-BORE <br /> p WELL# _ PRESSURE GROUT <br /> *Other--- _ Grout Specifications: <br /> COMMENTS: <br /> TYPE QF WELL INSTALLATION TYPE CONSTRUCTTQ?4 SPECIFICATIONS <br /> a MONITORING (]HOLLOW STEM DIA.OF BOREHOLE Z„ MULTIPLE CASINGS7 q YES N/NO WELL CASING DIA: <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: E STEEL O PVC 0 OTHER: <br /> U VAPOR 11 MUD ROTARY Dt PTH OF GROUT SEAL 4A 'TFzPMIE"TYPE TO BE USED: []AUGERS r�tOSE <br /> H AIR SPARGE lJ PUSH POINT GROUT SEAL PUMPED: ffeYes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IvSOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER- V0THER 4r#.c;I' &" APPROX.BORING DEPTHS4 - tJ� [)BOLTED TRAFFIC BOX or lJ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> `COMMENTS:P 0. Q FC 0V%M4.A+ ( S i-l'4. A4}e-S}ft%C,V t k A_ i c. _�c� D bLS� <br /> moi _ for Sta.� 1_ o.rtdl rr5w �va�-�v' `oaw.P�44. InaYnwe.1•< <br /> NOTE: OFFSITE MORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x,,�• ' TItlLfcompany <br /> Print Names�aV IAS MW m o of Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS-, <br /> WORK PLAN DATED: <br /> Application Accepted By _, Date Issued Area <br /> Grout Inspection By Date Final Inspection By nate <br /> Destntction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY, AID# <br /> PE CODES FEF INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br />